Background A US Food and Drug Administration safety letter warned about the risk for pneumothoraces during feeding tube insertion despite the use of electromagnetic placement devices that provide real-time visualization of feeding tube position. Objectives To systematically assess pulmonary placement and pneumothoraces in CORTRAK-assisted feeding tube insertions. Methods CINAHL, MEDLINE, and Cochrane databases were searched for studies of CORTRAK-assisted feeding tube insertion. Thirty-two studies documenting pulmonary placement and/or complications of feeding tube insertion were found. Results Operators recognized pulmonary placement on insertion tracings during 202 CORTRAK-assisted feeding tube insertion procedures, resulting in the immediate withdrawal of 199 feeding tubes. One pneumothorax was identified later by radiography. Seven pulmonary placements were not recognized by CORTRAK operators at the time of feeding tube insertion, resulting in 2 pneumothoraces. The incidence of pneumothorax for CORTRAK-assisted feeding tube insertions was 0.02% (3 of 17039). Of the feeding tubes inserted into the pulmonary system – either found during or after the procedure −1.4% (3 of 209) resulted in pneumothoraces (as opposed to the 19% to 28% incidence of pneumothorax for blind feeding tube insertions. Operators recognizing pulmonary placement on CORTRAK insertion tracings may have prevented 97% (202 of 209) of feeding tubes from being inserted farther into the respiratory tract. Conclusions Feeding tube insertion with an electromagnetic placement device is advantageous over blind feeding tube insertion because the operator can recognize pulmonary placement early and withdraw the feeding tube, thus decreasing the risk of pulmonary complications.

Background Little empirical evidence is available to guide decisions on what type of dressing to use and how often to change the dressing after placement of a thoracostomy tube. Objectives This prospective randomized controlled study was conducted to compare various dressing types and procedures after placement of thoracic and mediastinal chest tubes. Outcome measures included length of time between dressing changes, skin integrity, air leak presence, and patient-reported pain. Methods The study involved a convenience sample of 127 patients with 236 chest tubes from 3 intensive care units at a midwestern regional medical center. The patients were randomized to 1 of 3 groups: (1) gauze and tape dressing changed once daily, (2) gauze and tape dressing changed every 3 days, and (3) silicone foam dressing changed every 3 days. Results Patients with silicone foam dressings reported less pain at the insertion site than did patients with standard gauze and tape dressings, and patients with daily dressing changes reported significantly more pain with dressing removal than did patients with dressing changes every 3 days. The silicone foam dressing was associated with better skin integrity than the gauze and tape dressing. Dressing intactness, number of days with a chest tube inserted, and patient demographic characteristics did not differ significantly among the 3 groups. Conclusions Overall, the best type of dressing for promoting skin integrity and patient comfort was the silicone foam dressing. The results of this study may help identify best practices for dressing type and procedures among patients with chest tubes.

Background A variety of techniques are used for placement of small-bowel feeding tubes. Standard practice at the study institution is for postpyloric placement using an electromagnetically guided placement device (EMPD). EMPD placement is performed by bedside nurses trained in the placement technique and may reduce radiograph exposures and time to initiation of enteral nutrition. Objectives To evaluate how changes in SBFT placement verification procedures in critical care patients—from use of EMPD with radiographic confirmation, to placement verification by using EMPD without radiographic confirmation—influenced successful placement, misinterpretations of locations, and radiographic verification of tube locations. Methods The research was conducted at an 800-bed quaternary care referral hospital located in the Midwest. Nine-hundred four feeding tubes were placed in 632 critical care patients by using bedside EMPD instead of radiographic confirmation as the standard of care. Prospectively collected EMPD audit form data were retrospectively analyzed. Results Small-bowel (duodenum or jejunum) placement was achieved by bedside nurses in 97.2% of all EMPD placements, with 2.8% placed in the stomach because gastric placement was ordered or small-bowel placement could not be achieved. Radiographic confirmation was required in only 7.7% of placements. No adverse events or pulmonary placements occurred. Conclusions Use of EMPD technology allowed clinicians to safely and effectively place feeding tubes at the bedside and eliminate radiographs in most cases. EMPD placement was not limited to specialized nurses or teams. This procedure should be easily reproducible in other critical care environments.

Background Research has demonstrated the hazards associated with patients’ bath basins and microbial contamination. In a previous study, soap and water bath basins in 3 acute care hospitals were found to be reservoirs for bacteria and potentially associated with the development of hospital-acquired infections. Bacteria grew in 98% of the basin samples; the most common were enterococci (54%), and 32% were gram-negative organisms. Objective To assess the presence of bacterial contaminants in wash basins when chlorhexidine gluconate solution is used in place of standard soap and water to wash patients. Methods Bathing with chlorhexidine gluconate is the standard of practice for all patients in intensive care units at St Vincent Hospital. Specimens from 90 bath basins used for 5 days or more were cultured for bacterial growth to assess contamination of basins when chlorhexidine gluconate is used. Results Of the 90 basins cultured, only 4 came back positive for microbial growth; all 4 showed growth of gram-positive organisms. Three of the 4 organisms were identified as coagulase-negative staphylococcus, which is frequently found on the skin. This translates into a 95.5% reduction in bacterial growth when chlorhexidine gluconate is used as compared with soap and water in the previous study (Fisher exact test, P < .001). The only factor that was related to positive cultures of samples from basins was the sex of the patient. Discussion Compared with the previous study examining microbial contamination of basins when soap and water was used to bathe patients, bacterial growth in patients’ bath basins decreased significantly with the use of chlorhexidine gluconate, drastically reducing the risk for hospital-acquired infections. Such reduced risk is especially important for critically ill patients at high risk for bacterial infection.

Background Fecal contamination is a major challenge in patients in acute/critical care settings that is associated with increased cost of care and supplies and with development of pressure ulcers, incontinence dermatitis, skin and soft tissue infections, and urinary tract infections. Objectives To assess the economic impact of fecal containment in bedridden patients using 2 different indwelling bowel catheters and to compare infection rates between groups. Methods A multicenter, observational study was done at 12 US sites (7 that use catheter A, 5 that use catheter B). Patients were followed from insertion of an indwelling bowel catheter system until the patient left the acute/critical care unit or until 29 days after enrollment, whichever came first. Demographic data, frequency of bedding/dressing changes, incidence of infection, and Braden scores (risk of pressure ulcers) were recorded. Results The study included 146 bedridden patients (76 with catheter A, 70 with catheter B) who had similar Braden scores at enrollment. The rate of bedding/dressing changes per day differed significantly between groups (1.20 for catheter A vs 1.71 for catheter B; P = .004). According to a formula that accounted for personnel resources and laundry cycle costs, catheter A cost $13.94 less per patient per day to use than did catheter B. Catheter A was less likely than was catheter B to be removed during the observational period ( P = .03). Observed infection rates were low. Conclusion Catheter A may be more cost-effective than catheter B because it requires fewer unscheduled linen changes per patient day.